Provider Demographics
NPI:1558640227
Name:KOCIS, STACEY L (MT-10198)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:L
Last Name:KOCIS
Suffix:
Gender:F
Credentials:MT-10198
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 W IRON SPRINGS RD
Mailing Address - Street 2:STE 101
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3313
Mailing Address - Country:US
Mailing Address - Phone:928-308-1864
Mailing Address - Fax:
Practice Address - Street 1:1680 W IRON SPRINGS RD
Practice Address - Street 2:STE 101
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-3313
Practice Address - Country:US
Practice Address - Phone:928-308-1864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-10198225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist